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Dispensary observation. Patients with stage I hypertension, as

well as with stable mild and moderate stage II hypertension, are regis-

tered with a general practitioner. Patients with severe stage II hyperten-

sion, as well as patients with hypertension resistant to drug treatment,

remain under the supervision of a cardiologist of the polyclinic. All

persons who have come to the clinic for the rst time for any reason

should measure blood pressure, involving nursing sta. A specially

trained nurse in the oce lls out a questionnaire for the diagnosis of

hypertension in a polyclinic, measures blood pressure twice and writes

the numbers into an outpatient card. After repeated measurements of

blood pressure, the nurse gives advice on non-drug therapy and refers

the patient to the doctor.

In pregnancy, hypertension is the main cause of premature birth,

perinatal and maternal mortality (20-30% of cases), usually occurring

at a later date (later than 20 weeks) and disappearing within 6 weeks

after delivery. If hypertension develops early and persists longer than

6 weeks after childbirth, then the cause of the disease is more often

kidney disease, and therefore, during repeated pregnancy, such pa-

tients require especially careful monitoring.

Modern technology of medical care for patients with hypertension

also includes rational medical documentation. For patients with stable

hypertension who must receive antihypertensive drugs for life, a dis-

pensary observation sheet is lled out, which is a formalized insert in

an outpatient card. It dynamically presents the results of drug therapy,

taking into account the patient’s complaints, the value of blood pres-

sure and pulse, contains information about the side eects of drugs in

each case. The same list is proposed to be kept by a patient with hy-

pertension at home. The introduction of such sheets into the practice

of the therapist and cardiologist of the polyclinic makes it possible

to reduce the number of entries in the 025 / u form, free up time for

a more thorough examination of the patient and promptly manage the

pharmacotherapy of hypertension.

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Clinical case No. 6

1. What is the preliminary diagnosis? Coronary heart disease:

large-focal myocardial infarction. Violation of the rhythm of the type

of extrasystole (Premature heart beats).

2. What additional tests would you recommend to the patient, and

what are the expected results?

Laboratory tests

Basic examination in patients with coronary artery disease in-

cludes standard biochemical tests: troponin T or I, complete blood

count with hemoglobin and leukocyte counts, glycated hemoglobin

and plasma glucose fasting, serum creatinine and creatinine clearance,

blood lipid, thyroid function, liver function tests, creatinine phospho-

kinase, brain natriuretic peptide type B (BNP) or GC-B, peptide hor-

mone and its precursor ( BNP / NT-proBNP).

Instrumental studies

Electrocardiogram (ECG) at rest and / or during or immediately

after an attack of chest pain, outpatient ECG monitoring (in patients

with suspected arrhythmia and vasospastic angina), echocardiography

at rest to identify violations of regional contractility, determination

of ejection fractions and left ventricular diastolic function, ultrasound

examination of the carotid arteries to determine the thickness of intima

media and / or detection of atherosclerotic plaques, chest x-ray.

Studies according to indications

Non-invasive methods for diagnosing ischemia:

1) ECG stress test with exercise;

2) stress echocardiogram with exercise or using dobutamine or

a vasodilator;

3) exercise or vasodilator positron emission computed tomogra-

phy;

4) magnetic resonance imaging (MRI) of the heart with dobuta-

mine and vasodilator;

t.me/medicina_free

5) Hybrid imaging (single-photon emission computed tomogra-

phy) of the heart.

Non-invasive methods for assessing the anatomy of the coronary

arteries

Computed tomography of the coronary arteries is performed

without the introduction of a contrast agent or after intravenous ad-

ministration of iodine-containing contrast. Invasive coronary angi-

ography. Invasive coronary angiography is performed to determine if

revascularization is possible.

3. What is the patient’s management?

Medication. Currently, three classes of drugs are mainly used to

treat angina pectoris: nitrates, β-blockers, and calcium antagonists.

The goal of antianginal therapy is to reduce myocardial oxygen de-

mand and / or increase myocardial perfusion. Low-dose aspirin is

recommended for all patients with stable coronary artery disease.

Clopidagrel is recommended as an alternative drug in cases of aspi-

rin intolerance. Statins are recommended for all patients with stable

coronary artery disease. Angiotensin-converting enzyme inhibitors or

angiotensin II receptor blockers are indicated in the presence of heart

failure, hypertension and diabetes.

Nitrates. The main remedy for stopping an attack of angina pecto-

ris remains nitroglycerin in tablets for sublingual use. The eect usu-

ally comes quickly, after 1-3 minutes, the duration of the action is up

to 30 minutes. If one nitroglycerin tablet does not relieve the attack,

the dose can be repeated at approximately 5-minute intervals. It is

not recommended to take a total of more than 1.2 mg of nitroglyc-

erin within 15 minutes. If within 15 minutes after repeated doses of

nitroglycerin the attack does not stop or increases, then there is a high

probability of developing necrosis.

β-blockers. The drugs of this group are the basis of complex ther-

apy for stable exertional angina, as they reduce the frequency of an-

gina attacks and increase the pain threshold.

Calcium antagonists. This is a rather heterogeneous group of

drugs that have an eect on blood vessels (dilatation of coronary and

peripheral arteries) and on the heart (negative inotropic eect).

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The most pronounced vasodilating eect is possessed by nife-

dipine and other dehydroperidine derivatives (amlodipine, felodipine,

isradipine); negative inotropic eect - verapamil and other phenyl-

alkylamine producing agents (gallopamil, anipamil, falipamil). An

intermediate position is occupied by diltiazem. Recently, prolonged

forms of these drugs are increasingly used.

Other anti-ischemic drugs

Ivabradine is a selective inhibitor of the if-channels of the sinus

node of the heart, reduces heart rate and does not aect intra-atrial,

intraventricular conduction, is eective antianginal drug. The initial

dose is 5 mg 2 times a day.

Nicorandil is a nitrate derivative of nicotinamide that causes va-

sodilation of epicardial coronary arteries and stimulates ATP-sensitive

potassium channels in vascular smooth muscles. It is used at a dose of

20 mg 2 times a day.

Trimetazidine is an anti-ischemic drug that modulates myocardial

metabolism. It is used in a dose of 35 mg 2 times a day.

Ranolazine is an eective inhibitor of late sodium current with

anti-ischemic and metabolic properties. Starts at 500 mg 2 times a day.

Allopurinol is an inhibitor of xanthine oxidase, reduces the level

of uric acid in people with gout, antianginal eect in patients with

stable coronary artery disease. It is used in tablets of 600 mg per day.

Molsidomine is a direct donor of nitric oxide with an antianginal

eect. It is used 8 mg 2 times a day.

Combination therapy

In some patients with stable angina, one sublingual nitroglycerin

is sucient, but if attacks occur more than 2-3 times a week, it is

added β-blocker or calcium antagonist. If the attacks continue after

that, add prolonged nitrates. If necessary, use all three groups of drugs

(nitrates, β-blockers and calcium antagonists).

In combination therapy, the characteristics of each drug should

be taken into account. The combination of dihydroperidine calcium

antagonists (nifedipine) and prolonged nitrates (β-blockers) is not

an optimal combination, since both groups of drugs have a vasodila-

tory eect. In patients with severe left ventricular dysfunction, sinus

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bradycardia, atrioventricular conduction disorders, combination ther-

apy with β-blockers and calcium antagonists should be used with cau-

tion or not at all.

The combination of prolonged nitrates with calcium antagonists

of the dehydroperidine series is optimal in the treatment of patients

with disorders atrioventricular conduction. When a combination of

β-blockers, especially large doses, with calcium antagonists, their

negative inotropic eect must be taken into account.

Lipid-lowering therapy

All patients, in the absence of contraindications, should be pre-

scribed statins.

4. Medical and labor expertise. Dispensary observation.

Examination of working capacity. If myocardial infarction is not

Q-forming and uncomplicated (angina pectoris not more than I and

Chronic heart failure not more than I stage), employment is indicated

by a clinical expert commission. If MI is complicated (angina pectoris

Functional class no more than II and Chronic heart failure no more

than stage II) - also employment on the recommendation of the clini-

cal expert commission, in case of loss of qualications, send to the

Medico-social expert commission to determine the disability group.

If myocardial infarction is Q-forming uncomplicated (angina pectoris

Functional class no more than I and Chronic heart failure no more

than stage I), then persons of physical labor and / or a greater volume

of industrial activity should be sent to the Medical and Social Expert

Commission to establish a disability group. If myocardial infarction

is complicated (angina pectoris Functional class more than I-II and

Chronic heart failure no more than stage II), then regardless of the spe-

cialty, patients are also sent to the Medical and Social Expert Commis-

sion to establish a disability group. Spa treatment. After suering an

MI more than 1 year ago without angina attacks or with rare bouts of

tension without disturbing the rhythm and signs. With a higher func-

tional class of angina pectoris and heart failure, treatment is indicated

only in local sanatoriums.

Dispensary observation. The diagnosis of postinfarction car-

diosclerosis is established 2 months after the onset of myocardial

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infarction. It is during this period that the formation of cicatricial con-

nective tissue ends at the site of cardiac muscle necrosis. Patients who

underwent myocardial infarction should be followed up by a cardiolo-

gist for the rst year in a cardiological dispensary or polyclinic, and

follow-up is desirable for subsequent years. Observation frequency

and examination of patients with MI at the outpatient stage of rehabili-

tation. At the rst visit of the patient to the doctor, an outpatient card

is lled out, a plan for the management and treatment of the patient

is drawn up, an discharge summary and a plan of dispensary obser-

vation are written before discharge for work. II period of outpatient

treatment, the patient must visit the doctor once every 7-10 days, up

to discharge to work. Then after the 1st, 2nd week and the end of the

rst month of work. Then 2 times a month and the rst six months,

in the next six months - monthly. Second year - once a quarter. At

each visit to the patient, an ECG is taken. An exercise test (treadmill,

VEM, CPES) is performed after 3 months of MI development (in

some clinics in patients with uncomplicated heart attack at the end of

the 1st month of treatment), then before discharge for work and / or

when referral to medical and social expertise (MSEC). Then, at least

once a year. Echo–CG: upon arrival from a cardiological sanatorium,

before discharge to work and then once a year with Q-forming MI,

with an ejection fraction <35 or with LV dysfunction - once every

6 months, Holter ECG monitoring: after arriving from a sanatorium,

before a statement of work and referrals to MSEC, then once every

6 months. General analysis of blood, urine, blood glucose is examined

before discharge for work and / or when referring to the Medical and

Social Expert Commission, then once every 6 months in the 1st year,

and then at least once a year, ACT and ALT 2 times per year (if taking

statins). Study of the lipid prole: OC, LDL, HDL and TG 3 months

after the start of anti-sclerotic therapy, then every 6 months. Other

tests are done as indicated.

Clinical case No. 7

1. What is the preliminary diagnosis?

Preliminary diagnosis: Coronary heart disease: rhythm distur-

bance in the form of paroxysmal atrial brillation (tachysystolic form).

t.me/medicina_free

2. What additional tests would you recommend to the patient, and

what are the expected results?

Basic examination in patients with coronary artery disease in-

cludes standard biochemical tests: troponin T or I level, complete

blood count with hemoglobin and leukocyte counts, glycated hemo-

globin and fasting plasma glucose, serum creatinine level and assess-

ment of renal function by creatinine clearance, blood lipid spectrum,

assessment of thyroid function, hepatic function tests, creatinine phos-

phokinase level, brain natriuretic peptide type B (BNP) or GC-B level,

peptide hormone and its precursor (BNP / NT-proBNP).

Instrumental studies

Electrocardiogram (ECG) at rest and / or during or immediately

after an attack of chest pain, outpatient ECG monitoring (in patients

with suspected arrhythmia and vasospastic angina), echocardiography

(Echocardiography ) at rest to identify violations of regional contrac-

tility, determine ejection fractions and assess the diastolic function of

the left ventricle, ultrasound examination of the carotid arteries to de-

termine the thickness of intima media and / or detection of atheroscle-

rotic plaques, chest x-ray.

Tests according to indications

Non-invasive methods of ischemia diagnosis:

1) ECG -stress test with physical activity;

2) stress echocardiogram with exercise or using dobutamine or

a vasodilator;

3) exercise or vasodilator positron emission computed tomogra-

phy;

4) magnetic resonance imaging (MRI) of the heart with dobuta-

mine and vasodilator;

5) Hybrid imaging (single-photon emission computed tomogra-

phy) of the heart.

Non-invasive methods for assessing the anatomy of the coronary

arteries

Computed tomography of the coronary arteries is performed

without the introduction of a contrast agent or after intravenous ad-

ministration of iodine-containing contrast.

t.me/medicina_free

Invasive coronary angiography

Invasive coronary angiography is performed to determine the fea-

sibility of re.